No 22 - 2010

Imported brucellosis
Measles in Bulgaria
Registration of vaccine batch numbers
Change of invasive pneumococcal disease on reverse 

Imported brucellosis

Brucellosis is a bacterial zoonosis caused by Brucella species. Animal hosts comprise, among others, goats, sheep, cattle, deer, swine, dogs and camels. Human transfer occurs in connection with ingestion of unpasteurised diary products and by direct contact to infected animals during hunting, slaughterhouse work or other animal-related activities. Since 1964 Denmark has been a declared brucellosis-free area, but e.g. in the Middle East and Asia the disease is widespread. Brucellosis is not notifiable and the occurrence in Denmark is unknown, but the Reference Laboratory at the SSI receives 1-2 isolates annually.

In the following we describe a case of imported brucellosis:

Case history

A four-year-old girl, born in Denmark by Turkish parents was referred to a paediatric outpatient clinic after running a high fever for two weeks. Her GP had previously started her on penicillin therapy due to a positive Strep A test. The therapy had not lowered her fever. At the time of the referral, the girl's infection counts were largely normal, and she was - apart from running a high temperature and being tired - unaffected. On suspicion of pneumonia, the penicillin therapy was continued. Blood culture yielded small gram-negative sticks after four days, and the girl was therefore admitted to hospital. At admission the patient presented with evident splenomegaly, and small movable glandula in the axilla and groin were found during the otherwise normal physical examination. Brucella species were suspected, and the Reference Laboratory at the SSI identified the bacterial isolate as Brucellosis melitensis by mass spectometry (MS). Subsequently, the diagnosis was confirmed by species-specific PCR. The girl was prescribed six weeks of sulfamethoxazole/trimethoprim and rifampicine. She quickly recovered, and was afebrile 24 hours after treatment initiation. She had probably acquired the brucellosis during a family visit to a Turkish rural region three months prior to symptom onset. During the visit, the girl had ingested unpasteurised cow's milk and been in contact with cattle and goats. The Turkish family has subsequently stated that animals as well as their keepers were suffering from an undiagnosed disease at the time of the visit. The remaining family members, who had participated in the visit, were symptom-free.


Physicians should be aware of brucellosis as a differential diagnosis in connection with unexplained long-term fever in persons who have had contact with animals or who have ingested unpasteurised milk in brucellosis endemic areas. As Brucella species are very infectious, live cultures shall be transported and handled with particular care. On suspicion of Brucella species, the bacteria may before transport be dissolved in an alcohol-based solution that instantly inactivates the bacteria while also comprising the first step in the MS identification process. Rapid and safe identification of Brucella species is essential for the patient and for tracking of any other exposed persons, including laboratory staff.

(P. Ellekvist, Clinical Microbiology Department, Hillerød Hospital, M. Søndergaard, Paediatric Department, Hillerød Hospital, A. Kvistholm Jensen, M. Kemp, Dept. of Microbiol. Surv. & Research)

Measles in Bulgaria

The Bulgarian health authorities have reported an outbreak of measles, which started in April of 2009 and has subsequently escalated. A total of 20,000 cases have been reported, including more than 17,000 in 2010 and a total of 21 deaths have been reported, see

The majority of cases have occurred among ethnic Roma infants in the north east of the country; however, also older children and young adults have been reported later in the outbreak. The authorities have implemented an information and vaccination campaign to counter the outbreak.

Bulgaria has generally reported a high vaccination coverage, and it is therefore believed that the outbreak was caused by the lack of vaccinations among specific subsections of the population. The measles virus in circulation has been identified as genotype D4 and is identical to a measles virus which circulated during the first half of 2009 in Northern Germany.

The outbreak confirms that the measles virus is extremely infectious and that imported measles virus may transfer to groups of persons with a suboptimal vaccination coverage. This entails a risk of major outbreaks and serious illness. A risk which is also present in Denmark, EPI-NEWS 10/10.

Before travelling to a measles endemic area, MMR vaccination is recommended to any unvaccinated children above the age of nine months and any older children and adults who have not had measles or received vaccination previously, EPI-NEWS 25/06.

(S. Glismann, Department of Epidemiology)

Registration of vaccine batch numbers

Statens Serum Institut has received several queries as to which batch number should generally be registered in connection with vaccination. When registering Batch Number/Batch No./Lot., the number provided on the outside of the carton should be used. Some vaccines consist of several components, e.g. a vial with antigen and another with adjuvant. In such cases, the vaccines will carry an antigen as well as an adjuvant batch number, and an overall batch number on the outside of the carton. In such cases, it is important to register the batch number provided on the outside of the carton, as various combinations of antigen and adjuvant batches may occur.

(J.H. Jespersen, QA)

Change of invasive pneumococcal disease on the reverse

Since the beginning of 2010 all notifications of invasive pneumococcal disease (IPD) have been reported in a single line of table 1 on the reverse of EPI-NEWS. This has had the unfortunate consequence of excluding ongoing monitoring of the development of pneumococcal meningitis. As from this week, any cases of purulent meningitis will once again appear under "Purulent meningitis". In future, other cases of IPD in children below the age of five years will not be included on the reverse. This change will also apply to the annual report on individually notifiable diseases, EPI-NEWS 13-14/10.

(P.H. Andersen, Department of Epidemiology)

Individually notifiable diseases and selected laboratory diagnosed infections 

2 June 2010